Ivanov, David V

OBJECTIVES: To compare three fluoroscopic methods for determining femoral rotation. METHODS: Native femoral version was measured by computed tomography in 20 intact femurs from 10 cadaveric specimens. Two Steinmann pins were placed into each left femur above and below a planned transverse osteotomy which was completed through the diaphysis. Four surgeons utilized the true lateral (TL), neck-horizontal angle (NH), and lesser trochanter profile (LTP) techniques to correct the injured femur's rotation using the intact right femur as reference, yielding 120 measurements. Accuracy was assessed by comparing the angle subtended by the two Steinmann pins before and after manipulation and comparing against version measurements of the right femur. RESULTS: Absolute mean rotational error in the fractured femur compared to its uninjured state was 6.0° (95% CI, 4.6-7.5), 6.6° (95% CI, 5.0-8.2), and 8.5° (95% CI, 6.5-10.6) for the TL, NH, and LTP techniques, respectively, without significant difference between techniques (p = 0.100). Compared to the right femur, absolute mean rotational error was 6.6° (95% CI, 1.0-12.2), 6.4° (95% CI, 0.1-12.6), and 8.9° (95% CI, 0.8-17.0) for the TL, NH, and LTP techniques, respectively, without significant difference (p = 0.180). Significantly more femurs were malrotated by >15° using the LTP method compared to the TL and NH methods (20.0% vs 2.5% and 5.0%, p = 0.030). Absolute mean error in estimating femoral rotation of the intact femur using the TL and NH methods compared to CT was 6.6° (95% confidence interval [CI], 5.1-8.2) and 4.4° (95% CI, 3.4-5.4), respectively, with significant difference between the two methods (p = 0.020). CONCLUSIONS: The true lateral (TL), neck-horizontal angle (NH), and the lesser trochanter profile (LTP) techniques performed similarly in correcting rotation of the fractured femur, but significantly more femurs were malrotated by >15° using the LTP technique. This supports preferential use of the TL or NH methods for determining femoral version intraoperatively.

Objective: To determine whether operating on “major” vertebral fractures leads to premature abortion of surgery and/or other acute cardiopulmonary complications. Design: Retrospective review. Clinical Setting: Level 1 trauma center. Patients/Participants and Intervention: We retrospectively queried our institutional Trauma Rregistry for all cases presenting with concomitant rib fractures and surgically managed vertebral fractures. Main Outcome Measurements: The main outcomes included the surgical outcome (aborted vs. successfully performed), total and Intensive Care Unit length of stay (LOS), adverse discharge, mortality, and functional outcomes. Results: We found 57 cases with concomitant segmental rib fractures and surgically managed vertebral fractures. Seven patients (12%) received a rib fixation, of which 1 received before vertebral fixation and 6 after. Importantly, 4 vertebral fixation cases (7.02%) had to be aborted intraoperatively because of the inability to tolerate prone positioning for surgery. For case–control analysis, we performed propensity score matching to obtain matched controls, that is, cases of vertebral fixation but no rib fractures. On matched case–control analysis, patients with concomitant segmental rib fractures and vertebral fractures were found to have higher Intensive Care Unit LOS [median = 3 days (Inter-Quartile Range = 0–9) versus. 8.4 days, P = 0.003], whereas total LOS, frequency of complete, incomplete or functional spinal cord injury, discharge to rehab, and discharge to nursing home were found to be similar between the 2 groups. Conclusion: Our findings demonstrate that segmental rib fractures with concomitant vertebral fractures undergoing surgical treatment represent a subset of patients that may be at increased risk of intraoperative cardio-pulmonary complications and rib fixation before prone spine surgery for cases in which the neurological status is stable is reasonable. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.